More hospitals are finding that the strategic use of physician assistants (PAs) can improve quality and patient satisfaction without adding a financial burden. These physician extenders can reduce readmissions and improve ED efficiency, recent advocates say.
Hospital leaders and physicians are coming to understand the role of PAs better, says Dawn Morton-Rias, EdD, PA-C, president and CEO of the National Commission on Certification of Physician Assistants (NCCPA) in Johns Creek, GA. Rather than being another nurse or technician, the PA is educated and provides care much like a physician, she explains.
“PAs are educated in the medical model, which means their education, course work, their academic preparation resembles medication education very, very closely,” Morton-Rias says. “They work in collaboration with physicians during their training and sit for a very rigorous certification exam before acquiring their license. They are oriented to healthcare in a very similar way to physicians, and that is important to understand when you are considering the value of PAs and what they can do for your organization.”
In addition to being able to conduct many of the common tasks that physicians do, such as taking histories, conducting physical exams, and ordering laboratory studies, PAs also can provide continuity of care, she says. Transitions and continuity of care are increasingly important topics in healthcare lately, and Morton-Rias says PAs are ideally suited to managing transitions from hospital to home, for instance. That can significantly reduce admissions.
“Because hospital PAs are similar to physicians in terms of their education, they are not only well prepared with their clinical skills but they also have strong interpersonal skills,” she says. “They are adept at providing patient and family education, which are crucial in managing those transitions. Readmissions often occur because there has been some breakdown in the transition from the hospital experience to the home experience.”
PAs Catching on in Healthcare
PAs are among the most sought healthcare professionals now, and the demand is growing as hospitals and physician practices realize their value, Morton-Rias says. There are more than 108,000 certified PAs in the country now, and the number is growing. (See the story later in this issue for more information on the prevalence of PAs.) They are becoming more popular as healthcare leaders realize that PAs can help optimize both sides of the current healthcare focus on both quality and cost effectiveness. State licensing requirements vary from state to state, sometimes limiting the scope of a PA’s work in the hospital.
Research is proving their value. A recent study found that home visits by PAs after hospital discharge significantly reduces the chance that a heart surgery patient will be readmitted. (See the story later in this issue for more on that study.)
Physicians who were trained in the past several years typically worked with PAs during their education, Morton-Rias notes, and that makes them much more knowledgeable about PAs’ abilities and how to effectively work with them. She suggests that quality leaders who are interested in incorporating more PAs approach these physicians — particularly the younger ones — to get them on board and help advocate for the strategy.
“Physicians have been the greatest supporters of PAs in the last several years because they understand what they can offer,” she says. “They understand that this is not a role that takes anything away from the physician, but, in fact, allows the physician to focus more on the patient and improve quality of care.”
Patients Like Their PAs
Patients are receptive to PAs and usually respond well to their integration into a hospital or physician practice, Morton-Rias says. The only time the integration of PAs is not smooth is when the physicians were not consulted and educated about the move beforehand, she says. That lack of communication leads to confusion and mistrust about the role of PAs, she says.
PAs also can contribute in management positions. Ed Lopez, PA-C, is a PA and founder of a 110-member hospitalist group that covers five hospitals with a mix of 70% physicians and 30% PAs and nurse practitioners (NPs). He is facility medical director at St. Elizabeth Hospital/CHI Franciscan, which includes a 25-bed critical access hospital and an 80-bed nursing home in Seattle. With pay-for-performance bringing more pressure for quality, Lopez and his colleagues have focused on issues such as reducing readmissions, with PAs a key part of the strategy.
When CMS started putting pressure on hospital readmissions and threatened to reduce reimbursement, Lopez realized that the hospital was on shaky ground with a 30-day readmission rate of 35%. In response, he implemented a program that made use of PAs to reduce the rate significantly. (See the stories later in this issues for more on that effort, and for another case study.)
High Expectations for PAs
To use PAs effectively, they and the physicians must understand how to work together, he says.
“We hire people who understand this is an integrated program, with physicians and PAs working closely and cooperatively,” Lopez says. “There is virtually no difference in the level of performance, expectations, responsibility between the PA and the physician. A physician or a PA is expected to perform at the highest level possible of their licensure.”
That means PAs admit patients and follow them through care at the hospital, discharge the patient, have difficult conversations about death and dying, and rounding patients in the nursing home. Most of the PAs have been trained in hospice care and palliative care as well as internal medicine, Lopez says.
“Some executives in the hospital system have called us the Special Ops of hospital medicine, we have to do so much with so little,” Lopez says. “As a 25-bed critical access hospital we don’t have the luxury of a large group of consultants to call on as needed, so we rely on our PAs and physicians to have a wide range of talents and abilities, and we work in a collaborative way. We have PAs with 20 years’ experience who have a greater knowledge base than physicians who have four years in medicine, and they can both learn from each other.”
SOURCES
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Ed Lopez, PA-C, Facility Medical Director, St. Elizabeth Hospital/CHI Franciscan, Seattle. Telephone: (253) 468-7988. Email: [email protected].
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Dawn Morton-Rias, EdD, PA-C, President and CEO, National Commission on Certification of Physician Assistants, Johns Creek, GA. Telephone: (678) 417-8108. Email: [email protected].
Case Study 1: PAs Central to Reducing Hospital Readmissions
With CMS warning that high readmission rates could lead to low reimbursement, Ed Lopez, PA-C, facility director at St. Elizabeth Hospital/CHI Franciscan in Seattle, took a look at the hospital’s numbers and didn’t like what he saw: 35% of patients discharged to the system’s nursing home were readmitted within 30 days.
“It scared me to see that number,” Lopez says. “That was completely unacceptable. Before long, the nursing home came to us and said they were tired of doing business the way they’ve always done it and they wanted to partner with us to assume some responsibility for the patients.”
Lopez worked with the nursing home administrators to develop a plan in which hospitalists from St. Elizabeth, often PAs, would round at the nursing home on a daily basis, managing patients that had been transferred from the hospital. The PAs were available around the clock, seven days a week. Additionally, if the nursing home thought a patient needed to be readmitted to the hospital, a PA would visit the nursing home to evaluate the patient and look for other potential solutions.
The effort also required a culture change, reminding clinicians that they should care about what happens to patients after discharge and helping them get over the natural tendency to avoid nursing homes because they’re not thought of as pleasant places to visit.
“A readmission is not without work. The sell for me was to show that it would be easier to just go over and see the patient when we hear that there is a potential problem and avert an admission that would take us an hour and half,” Lopez says. “In 20 minutes at the nursing home we’ve avoided that hour and half of readmission work, not to mention the costs and the fact that people don’t want to be readmitted to the hospital.”
Patients respond very well to the idea that their treating physician or PA will see them in the hospital, with many amazed because they feel neglected and forgotten in the nursing home, Lopez says. Nurse recruitment also improves when nurses see that they will have the necessary support from physicians and PAs, he says.
“Within six months we saw the readmission rate drop to 15% and the readmission rate across all our facilities is now 4%,” Lopez says. “The message that has sent to our facilities and the CHI mother ship is that when the hospitalist group connects with a large cohort of potential readmissions and controls them, it makes a tremendous difference.”
The hospital built on that success by adding more discharge professionals to work with patients discharged into the community rather than the nursing home.
